When running a counseling private practice, having the right paperwork ensures compliance, provides clarity for clients, and protects your practice. The essential private practice forms for counseling clients include a HIPAA privacy form, a Good Faith Estimate (GFE), informed consent, progress notes, and a bio-psychosocial assessment. This blog will go step by step through the critical private practice forms you need in order to see an initial client, but also all the forms you should have on hand for your private practice.
If you take insurance, additional forms like an assignment of benefits, treatment plan, and mental status exam are required. This blog will break down the key documents every therapist needs, with links for free mental health private practice forms and attorney-approved forms to make your practice run smoothly.
What Forms Are Required for New Counseling Clients in Private Practice?
The necessary paperwork for new counseling clients in private practice is vital for legal, ethical, and clinical reasons. Let’s review the essential forms you’ll need.
HIPAA Privacy Form: The HIPAA privacy form ensures compliance with federal regulations by outlining how client health information will be protected. This form is a must-have for safeguarding client confidentiality and staying compliant with privacy laws. It’s one of the first documents a client should sign.
Good Faith Estimate (GFE): A GFE is crucial under the No Surprises Act, which mandates that clients receive an estimate of treatment costs. This form promotes transparency in your private practice and ensures clients are aware of fees upfront, reducing the risk of financial misunderstandings. This form is required for private pay clients and clients who are insured but choose not to use their insurance.
Informed Consent: This private practice intake form for counseling, outlines the counseling process, risks, benefits, client rights and so much more. An informed consent form protects both you and your clients by setting clear boundaries for treatment. A good informed consent is lengthy, but it ensures clients understand what to expect from your services. This form also covers private practice counseling policies and procedures.
Bio-psychosocial Assessment: This assessment gathers essential information about a client’s mental, social, and physical health. It’s often part of the intake process and provides a comprehensive understanding of the client’s background.
Progress Notes: These notes document each session’s content, goals, and outcomes. They also note any critical events like suicide risk assessment, abuse reporting, etc. Though they aren’t client-facing forms, they are essential for tracking a client’s progress and are a requirement.
If you take insurance, there are additional forms required:
Assignment of Benefits (AOB): It’s necessary for any practice that processes insurance claims.
Treatment Plan: For insurance purposes and effective therapy, a detailed treatment plan outlining the client’s goals, objectives, frequency, and target date for achieving them is required. It provides structure to the therapeutic process and helps in tracking progress.
Mental Status Exam (MSE): This is used to document a client’s psychological functioning at a given time. It’s another form that can be important, especially if your practice works with insurance.
Finally, you should also have these forms on hand, especially during an initial intake with a client:
Release of Information (ROI): In cases where you need to collaborate with other healthcare providers or institutions, the private practice release of information form grants you permission to share a client’s confidential information. This form is also known as the HIPAA release form or HIPAA psychotherapy authorization form.
Suicide Risk Assessment & Client Treatment Compliance Agreement: Having this form on hand is critical for assessing and documenting a client’s risk of self-harm. Therapists never know when a situation will arise where the client presents as a risk to self or others.
Think of these forms as your private practice startup paperwork. By starting your private practice with these forms, you will cover both client care and legal obligations, ensuring your practice is fully compliant and protected as well as protecting your clients.
What Other Forms Should I Have for My Counseling Private Practice?
In addition to the essential forms discussed earlier, there are several other documents that can enhance the efficiency, compliance, and overall operation of your private practice. While not all forms are mandatory, having them available can streamline your practice and ensure you are prepared for a wide range of situations. Below are key additional forms from The Private Practice Startup to consider for a well-rounded private practice paperwork system.
1. Biopsychosocial Forms for Adults, Children, and Couples
While the biopsychosocial assessment was mentioned as a critical intake form, it is worth noting that tailored versions of this form should be used depending on your client population. For instance:
Adult Biopsychosocial Assessment: Focuses on adult-specific mental, physical, and social health factors.
Child Biopsychosocial Assessment: This version is adjusted to reflect developmental stages, school performance, and family dynamics.
Couples Biopsychosocial Assessment: Explores relational history, communication patterns, and couple-specific issues.
Using these tailored forms allows you to gather relevant information based on the client type and provides a more personalized treatment plan, ultimately improving the effectiveness of your therapy.
2. Collection Letter for Past Due Therapy Services
Late or non-payment for services is a situation private practitioners encounter. To address this, it’s essential to have a well-drafted Collection Letter for Past Due Therapy Services. This form is used to remind clients of their financial obligations to the practice in a professional yet firm manner. It should outline the balance owed, the potential consequences of non-payment, and any available payment options. Having a formal process in place for late payments protects your business and keeps financial conversations clear and professional.
3. Discharge/Therapy Termination Summary
The Discharge or Therapy Termination Summary documents the end of treatment, including the reasons for termination (whether initiated by the client or therapist), goals achieved, and any ongoing recommendations. This form is crucial not only for client records but also to reduce liability. For example, if a client was recommended to a higher level of care say in-patient substance abuse treatment, and the client was unwilling this should be documented that the therapist took the appropriate steps and actions of recommending a higher level of care and provided resources.
4. Documentation/Communication Form for Counseling
A Documentation/Communication Form allows therapists to record any contact or communication with a client or outside provider outside of therapy sessions, such as phone calls or emails. This form ensures that all communications are documented, providing a legal record and enhancing client care by tracking out-of-session interactions. Of course, if you are collaborating with another professional, agency or organization ensure you have a release of information signed prior to doing so.
5. Email Confidentiality Notice
In today’s digital age, email is a common method of communication between therapists and clients. However, email carries inherent risks. An Email Confidentiality Notice form should be included as part of your email signature on your HIPAA-compliant email platform, informing clients that email is not entirely secure and may not comply with HIPAA privacy standards. This notice helps set boundaries and expectations around digital communication and protects your practice from potential confidentiality breaches.
6. Group Counseling Consent
If you offer group therapy sessions, a Group Counseling Consent form is a must. This form outlines the expectations and rules for group participation, including confidentiality within the group, the role of the therapist, and how group members are expected to interact. It also ensures that participants understand the group dynamics and agree to respect the confidentiality of others in the group setting.
7. Media Consent Form for Therapy Client Data for Research and Training
In some cases, you may want to use client data for research or training purposes. A Media Consent Form allows clients to consent to their data being used for these purposes. This form ensures compliance with legal and ethical standards, and clients must provide explicit consent before any of their information is shared for research, presentations, or educational training.
8. Psychological Evaluation and Testing Consent for Psychologists
For psychologists who perform formal assessments, it’s essential to have a Psychological Evaluation and Testing Consent form. This document outlines the nature of the testing, its purpose, and what clients can expect from the results. Clients must understand that testing results may influence diagnoses or treatment plans and should provide informed consent before the evaluation begins.
9. Sliding Scale Therapy Payment Agreement
A Sliding Scale Therapy Payment Agreement is useful if you offer income-based payment options for clients with financial constraints. This agreement outlines the terms of the reduced rate, why consideration for a sliding scale is necessary, and any conditions for maintaining the sliding scale rate (e.g., periodic income verification). Having a formal agreement protects both you and your clients, ensuring clear financial expectations.
10. Substance Abuse Intake Assessment
For therapists specializing in addiction or substance abuse, the Substance Abuse Intake Assessment is essential for gathering detailed information on a client’s substance use history. This form delves into the client’s drug and alcohol use, treatment history, and social impact, offering a comprehensive view of their needs and setting the foundation for a tailored treatment plan.
11. Therapy Superbill Template
If you have clients who wish to submit their therapy costs to their insurance companies for reimbursement, a Therapy Superbill Template is an essential form. This document summarizes the services provided, including diagnostic and ICD codes and treatment dates, and enables the client to seek reimbursement for out-of-network services. Offering this form enhances client satisfaction and adds professionalism to your practice.
12. Telehealth Consent
As telehealth becomes more prevalent, having a dedicated Telehealth Consent form is critical. This can be combined with informed consent or can be kept separate depending on your practice. This document covers the unique aspects of providing therapy remotely, including the technology used, benefits and risks, potential risks to confidentiality, and limitations on the therapist’s ability to provide immediate crisis support during virtual sessions. This consent ensures both legal compliance and that clients are fully informed about the telehealth process.
13. Welcome Letter for New Counseling Clients
A Welcome Letter for New Counseling Clients is a personalized way to introduce new clients to your practice. This letter can provide essential information such as office policies, contact information, session expectations, and even a brief overview of what clients can expect during their first few sessions. A well-crafted welcome letter sets a positive tone and helps new clients feel more comfortable from the start.
What Is an Informed Consent Form, and Why Is It Essential?
An informed consent form is one of the most crucial documents in private practice counseling. It is a required document, and it outlines the nature of therapy, the methods used, the potential risks and benefits, limits to confidentiality and so much more. Clients must understand what they are consenting to before beginning treatment, and this document serves as a legal record of their agreement.
This therapy consent form template also includes information on a therapist’s fees, cancellation policy, social media policy, structure and length of therapy, phone contact, emergencies, and electronic communications. In essence, it lays the foundation for trust and transparency between therapist and client, ensuring that both parties are aware of their rights and responsibilities.
Having a well-drafted informed consent form reduces the likelihood of misunderstandings, ensuring that clients know exactly what they are getting into and what to expect during therapy. This form is critical for protecting your practice legally while ensuring ethical transparency with clients. It is always recommended to review the informed consent verbally with the client at the beginning of their first session.
What Is the Difference Between a HIPAA Privacy Notice Form and a Release of Information Form?
The HIPAA Privacy Notice Form and the Release of Information (ROI), serve different purposes but are both essential for compliance and confidentiality.
HIPAA Privacy Notice Form: This form ensures that clients understand how their health information will be used and protected. It explains the limits of confidentiality, and client rights and details how you comply with HIPAA laws. Clients must sign this form at the start of treatment. It does not authorize the release of any specific information but serves to outline privacy protocols.
Release of Information (ROI) Form: In contrast, the ROI form is used when you need to share or request a client’s protected health information (PHI) with third parties, such as other healthcare providers, schools, or legal entities. Clients must sign this form for each instance where their PHI will be disclosed, ensuring that they maintain control over their private information.
If you’re looking for free mental health private practice forms, grab your FREE HIPAA Privacy Form Template, visit this link.
Are Telehealth-Specific Consent Forms Required, and What Should They Include?
Yes, telehealth-specific consent forms are required if you offer telehealth sessions. This could be via phone or video. These forms differ from standard consent forms because they address the unique aspects of providing therapy over video or phone.
A telehealth consent form should include:
A statement of informed consent for remote sessions.
Details on limits of confidentiality and how confidentiality will be maintained during virtual sessions.
Risks and benefits of telehealth therapy.
Information on the technology being used and potential risks, such as data breaches.
Any limitations of telehealth, including the therapist’s ability to provide emergency services.
Including telehealth consent forms in your private practice paperwork is vital to ensuring compliance with state regulations and protecting client confidentiality in the digital age. This form can be included with your informed consent, or it can be separate.
What Should Be Included in a Good Faith Estimate Form for Therapists in Private Practice?
A Good Faith Estimate (GFE) form provides clients with an estimate of the cost of services, as required by the No Surprises Act. This form promotes financial transparency and helps clients avoid unexpected fees. Here’s what you should include in your GFE:
Identifying information of the client - name, phone number, date of birth, and address.
Therapist’s identifying information - name, practice name, address, contact information, EIN, and NPI (if applicable)
Client diagnosis if known.
The estimated cost of therapy sessions over a specified period.
A clear breakdown of any additional fees (e.g., missed appointments, late cancellations).
A statement that the estimate is not a contract, and actual costs may vary.
GFE disclaimer and how to file a dispute.
To be in compliance with the No Surprises Act and Good Faith Estimate you need both a website notice and office notice as well. Providing this form and information to clients helps you remain compliant with federal law while promoting a transparent practice.
Get your FREE Good Faith Estimate Template and other needed forms here.
Where Can I Find, Attorney-Approved Counseling Forms for Private Practice?
Starting your private practice doesn’t have to involve costly legal consultations for forms. You can find attorney-approved private practice forms online that meet legal standards at the Private Practice Paperwork Peak.
This resource from private practice therapists, provides a wide range of forms, including those for intake, client policies, informed consent, telehealth, and many more. It includes 20+ forms over 80+ pages you need for your counseling private practice. By using these customizable templates, you can confidently manage your private practice with all the necessary documentation in place, without the need for paying expensive attorney fees to create them on your own.
Ready to Get Your Private Practice Paperwork in Order?
Running a counseling private practice requires having the right paperwork in place to protect your clients, maintain compliance, and streamline your operations. The Private Practice Startup offers a comprehensive bundle of essential Attorney-Approved private practice paperwork forms for every aspect of your practice, from intake to progress notes to telehealth consents, all designed to simplify and protect your practice. Here’s how to get started:
Ask Any Questions – Have questions or need more details? Reach out to Kate@ThePrivatePracticeStartup.com for guidance on which forms fit your needs.
Download Your Paperwork Bundle – Access our Attorney-Approved Private Practice Paperwork Bundle, covering everything from HIPAA compliance to Good Faith Estimates.
Start Using the Forms Today – Simply add your practice details and start using these legally sound, professional forms to serve your clients confidently and compliantly.
Additional Services Offered By The Private Practice Startup
At The Private Practice Startup, we’re dedicated to empowering your practice’s growth and success. Alongside our customized private practice paperwork packages for mental health professionals, we provide essential supervision forms, Good Faith Estimates, and HIPAA-compliant documents tailored to meet your unique needs. Looking to expand your client base? Our comprehensive Private Practice Marketing E-Course walks you through effective strategies for client attraction and retention. Tune into the Private Practice Startup Podcast for valuable insights from industry experts, experienced therapists, and successful entrepreneurs. Whether you’re practicing in Texas, New York, or anywhere else, we’re here to help you achieve your practice goals.